July 2014Brad Weir MD, EMTP, FAAEM, FACEP

Standard of care in EMS for past forty years

Has been regarded as an essential component for a large majority of trauma patients

One of the main skills that all of us learned in EMT class

Spinal Motion Restriction (SMR): current and biomechanically more accurate term

Evidence-based emergency medicine/systematic review abstract. Is routine spinal immobilization an effective intervention for trauma patients? Ann Emerg Med. 2006;47(1):110–112.

Spine immobilization in penetrating trauma: More harm than good? J Trauma. 2010;68(1):115–120; discussion 120–121.

Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso. J Trauma. 2009;67(4):774–778.

Prehospital procedures before emergency department thoracotomy: ‘Scoop and run’ saves lives. J Trauma. 2007;63(1):113–120.

Moves from the concept of assuming almost every trauma patient has an unstable spine injury, to the reality that very, very few of them do

Avoids the dangers of immobilization- induced injury, extended scene time, etc.

Brian E. Bledsoe, D.O. Paramedic, physician. Lead author of

Paramedic Emergency Care.

Wrote an article entitled “Spinal Immobilization, Have We Gone too Far?” which was published in JEMS

IN 1994!

Paramedic level care in Australia has used backboard immobilization only for a very few selective cases for over twenty years, with outcomes as good for spinal cord injury as the American system.

“There have been no reported cases of spinal cord injury developing during appropriate normal handling of trauma patients who did not have

a cord injury at the time of trauma.”

Domeier et al.

EMS Medical Directors and Trauma Surgeons

Joint Position statement in December 2012 Paper follows NEXUS guidelines This was the main impetus for the new

Region VI protocol

Consider that full immobilization:◦Increases aspiration risk and atelectasis.◦Makes airway management more

difficult.◦Increases intracranial pressure.◦Increases the incidence of pressure sores

(sometimes in less than 1 hour).

◦Is a pain in the back (try lying on a board yourself).

◦Frequently fails to achieve a neutral alignment.

◦Is difficult to remove without lumbar movement.

◦Increases combativeness in drunk patients.

◦Is expensive.◦Is time consuming to apply.

NEXUS study, Canadian C-Spine study Almost all fractures- and all unstable

fractures- could be identified based on clearance criteria: ◦Midline tenderness◦Lack of distracting injury or intoxication◦Neurologic deficit.

Several major EMS systems have begun protocols that dramatically reduce spinal immobilization (Albuquerque, Indianapolis, St. Louis)

January 2013- NAEMSP meeting:

“There is no proven benefit to rigid spinal immobilization as practiced in the United States.”

March 2013-Indianapolis EMS dramatically reduced spine board utilization

Our current c-spine clearance protocol does not address thoracic & lumbar spine and is seldom used

Approved by Carle Level 1 Trauma services Medical Directors

Discussion of Region VI protocol at May EMS Medical Directors’ meeting

Notes: 1.The spine examination must be completed by the Paramedic. Other responders may apply c-collar and package the patient for transport on a long spine board as appropriate.

2.Penetrating trauma patients DO NOT require transport on a long spine board.

3. Patients who are ambulatory on EMS arrival generally DO NOT require full spinal motion restriction on a long spine board UNLESS any condition in Criteria A is present.

4. Patients outside these guidelines will be treated by the judgment of the Paramedic on scene, with the assistance of online medical control if needed.

High Risk Spinal Injury Criteria: These include, but are not limited to: 1.Ejection from motor vehicle2.Separation from motorcycle/ATV3.Vehicle rollover4.Prolonged extrication5.Pedestrian struck by vehicle at speed > 20 mph

High Risk Spinal Injury Criteria cont:

6.Falls > 3x patient’s height7.Suspected dive into shallow water 8.Hanging9.Signs of spinal cord injury from a blunt mechanism 10.GCS < 14 11.Depressed or open skull fracture

A. Full spinal motion restriction (c-collar, CIDs, and long board) should be used for High Risk Spinal Injury Criteria AND any of the following:

A. Unconscious during examB. Altered mental statusC. IntoxicationD. Language barrierE. Neurologic deficit present or reported. F. Any thoracic or lumbar spine deformity, or

midline tenderness on palpation or with movement.

B. Cervical-collar-only motion restriction should be applied to blunt trauma patients with ANY of the following:

1. Presence of cervical deformity or midline tenderness on palpation or movement.

2. Age > 65. 3. Distracting injury present.4. High Risk Spinal Injury Criteria.5. Paramedic’s discretion.

C. It is always acceptable to use a long spine board for extrication. Patients who do not meet any of the above criteria in (A) should be logrolled off of the long board onto the cot and be seat belted for transport. This includes those patients packaged by other responders. Patients with back pain should be transported supine, and reasonable effort to slide as a unit between EMS cot and receiving hospital bed should be made.

D. Additional long spine board indications include: 1. Lower extremity fractures- to support

splinted limb(s)2. CPR- to enhance compressions

E. Pregnancy: Third trimester pregnant patients who need to be immobilized on a long spine board should have the board tilted ~25 degrees into the left lateral recumbent position.

F. Children: Secure children in their car seats. If car seat is unavailable or child was unsecured in a MVA, the child should be fully immobilized so long as doing so does not cause the child to struggle and compromise the SMR effort